AUTHORIZATION FOR MINOR'S MEDICAL TREATMENT Child Full Legal Name: ___________________________________________________________________ Date of Birth: _______________________ Age: ___________ Gender: ___________ Doctor’s Information Doctor’s Name: ____________________________________________________________________ Doctor’s Address: __________________________________________________________________ Doctor’s Office Phone: ____________________ Doctor’s Emergency Phone: __________________ Medical Insurer/Health Plan: __________________________ Policy #: ______________________ Allergies to Medications: _____________________________________________________________ Allergies (Other): ___________________________________________________________________ If applicable, please note the conditions for which the child is currently receiving treatment: _____________________________________________________________________________ ____ Note any other significant medical information: _____________________________________________________________________________ ____ _____________________________________________________________________________ ____ Dentist’s Information Dentist’s Name: ____________________________________________________________________ Dentist’s Address: __________________________________________________________________ Dentist’s Office Phone: ____________________ Dentist’s Emergency Phone: __________________ Dentist’s Insurer/Health Plan: __________________________ Policy #: _____________________ Parent(s)/Legal Guardian(s): Parent #1: Name: ___________________________________________________________________________ Address: ________________________________________________________________________ Home phone: __________________________ Work phone: ____________________________ Cell phone: ____________________________ Pager: _________________________________ Email: ________________________________ Additional Contact Information: _______________________________________________________ _____________________________________________________________________________
____ Parent #2: Name: ___________________________________________________________________________ Address: ________________________________________________________________________ Home phone: __________________________ Work phone: ____________________________ Cell phone: ____________________________ Pager: _________________________________ Email: ________________________________ Additional Contact Information: _______________________________________________________ _____________________________________________________________________________ ____ Alternate contact in the event Parent(s)/Legal Guardian(s) cannot be reached: Name: ___________________________________________________________________________ Address: ________________________________________________________________________ Home phone: __________________________ Work phone: ____________________________ Cell phone: ____________________________ Pager: _________________________________ Email: ________________________________ Additional Contact Information: _______________________________________________________ _____________________________________________________________________________ ____
AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S) I do hereby solemnly swear that I have legal custody of the aforementioned minor child. I grant my authorization and consent for _________________________________________ (hereafter “Supervising Adult”) to administer general first aid treatment for any minor injuries or illnesses experienced by the minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Supervising Adult to summon any and all professional emergency personnel to attend, transport, and treat the participant and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Supervising Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel. This authorization is effective commencing on the ______day of ____________________, 20_____ and expiring on the ______day of ____________________, 20____. Signed this ______day of____________________, 20 ____.
______________________________________ Parent #1’s Signature
______________________________________ Parent #2’s Signature
CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC STATE OF __________________ COUNTY OF ________________ This document was acknowledged before me on ______________________ [date] by ________________________________________________ [name of principal]. [Notary Seal, if any]: _______________________________ (Signature of Notarial Officer) Notary Public for the State of ______________ My commission expires: __________________